2000 Volume 28 Issue 4 Pages 254-259
Patients with carotid artery stenosis frequently have other systemic disease such as hypertension, diabetes mellitus and ischemic heart disease.
For better prognosis after carotid endarterectomy (CEA) management of these systemic diseases is essential. On the other hand, systemic management for cerebral ischemia during cross-clamping of the internal carotid artery (ICA) at CEA and postoperative hyperperfusion after CEA are also needed. The purpose of this study is to develop a rational plan for the systemic management of patients undergoing CEA.
In 154 patients with carotid artery stenosis 168 CEAs were done. T-shaped intraluminal shunt was used in all patients. The average age of the patients was 63 years. The average degree of stenosis on the operated side was 66%.
Fifty-seven of the patients had hypertension, 32% had hyperlipidemia, 22% had ischemic heart disease, and 20% had diabetes mellitus. Coronary angiography was done in 16 patients, and significant coronary artery stenosis was seen in 12 patients. Coronary arteries were reconstructed in 7 of these patients. Coronary artery bypass grafting (CABG) was done in 1 patient and PTCA in 1 patient before CEA. In 6 patients the coronary artery was reconstructed after CEA. Simultaneous CEA and CABG were not performed. There was no cardiac complication during CEA. The management strategy for simultaneous carotid artery stenosis and coronary artery disease depends on the hemodynamic severity of each disease. In patients with poor collateral circulation, cross-clamping of the ICA will induce cerebral ischemia. Somatosensory evoked potential (SEP) was more sensitive for detection of cerebral ischemia during ICA cross-clamping than other monitorings of ICA stump pressure and cerebral oxyhemoglobin concentration. The shunt system was useful for decreasing time of ischemia.
Hyperperfusion could be predicted by marked increase (≥180ml/min) in ICA flow after CEA and by increased flow velocity of the middle cerebral artery (MCA), which could be measured by transcranial Doppler sonography. As MCA flow velocity after CEA increases until 2 days after CEA, systemic arterial blood pressure must be controlled until several days after CEA. When control of blood pressure is difficult, barbiturate treatment should be considered.
